Chapter 31

Obstructive Pulmonary Diseases

Bridge to NCLEX Examination – Answers to Test Questions

1. Correct answer: a

Rationale: If hemoptysis occurs, the patient should contact the HCP. In some patients, a spot of

blood is usual. The HCP should give specific instructions about when emergency contact is

needed. The other indicators listed are to be expected in the patient with bronchiectasis, and do

not need urgent medical attention.

2. Correct answers: a, b, c, e

Rationale: Airway clearance techniques include chest physiotherapy, positive expiratory

pressure devices, breathing exercises, and high-frequency chest wall oscillation systems.

Bronchodilators and mucolytics are an important part of this plan. Severe constipation can be

treated with polyethylene glycol (PEG) electrolyte solution, which is used to thin bowel contents.

Inhaled tobramycin is effective in patients with CF who have Pseudomonas infections.

3. Correct answers: b, c, d

Rationale: Allergic rhinitis is a major predictor of adult asthma. Acute and chronic sinusitis,

especially bacterial rhinosinusitis, may worsen asthma. The chronic inflammation of asthma

leads to recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly

at night or in the early morning. GERD is more common in people with asthma than in the

general population. GERD may worsen asthma symptoms because reflux may trigger

bronchoconstriction and cause aspiration. Chest pain and syncope after five minutes of exercise

are not normal for the patient with asthma, and patient should be encouraged to report these

specific findings to their HCP for additional follow-up.

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4. Correct answers: a, c, e

Rationale: Status asthmaticus is characterized by a lack of response to conventional treatment.

This is potentially a life-threatening medical emergency, which may require mechanical

ventilation in the ICU. As the patient is keenly aware that response to treatment is not working,

anxiety and panic may be observed. If the patient can speak in complete sentences, or, has a

PEFR >300L/min, then there is no immediate threat to the respiratory system. A chest x-ray with

hyperinflated lungs and a flattened diaphragm is strongly suggestive of COPD. A positive

sputum culture indicates lung infection.

5. Correct answers: a

Rationale: A rescue plan for patients with asthma includes taking 2 to 4 puffs of a short acting

bronchodilator (not a corticosteroid) every 20 minutes (3 times) to obtain rapid control of

symptoms. All other patient statements identify to the nurse that the patient has accurate

knowledge about his condition.

6. Correct answers: d

Rationale: The mainstay of acute asthmatic treatment is inhalation of short-acting β2adrenergic

agonist (SABA) bronchodilators, such as albuterol (ProAir HFA, Proventil HFA, Ventolin HFA).

In patients with a moderate to severe attack, inhaled ipratropium (Atrovent) is used in

conjunction with SABA. Salmeterol (Serevent Diskus) and montelukast (Singulair) are long-term

control medications. Inhaled hypertonic saline is used in cystic fibrosis and bronchiectasis to help

thin secretions. IV Theophylline is no longer recommended for the treatment of acute asthma

attacks or in COPD exacerbations because of a very narrow therapeutic window, the availability

of newer and more effective drugs, and, significant adverse effects (e.g., seizures and

dysrhythmias).

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7. Correct Answers: a, c, e

Rationale: Breathing exercises may assist the COPD patient during rest and activity (e.g.,

lifting, walking, stair climbing) by decreasing dyspnea, improving oxygenation, and slowing the

respiratory rate. Walking (or other endurance exercises, such as cycling), combined with strength

training, when possible, are probably the best interventions to strengthen muscles and improve

the endurance of a patient with chronic obstructive pulmonary disease (COPD). Low dose oral

corticosteroids may be appropriate for chronic COPD patients. Frequent chest x-rays are not

needed.

8. Correct answer: d

Rationale: The patient needs to know the correct way to determine if the metered-dose inhaler

(MDI) is empty. The patient should divide the total number of puffs in the canister by the puffs

needed per day. The other three statements are not correct.

Answers to Case Study Discussion Questions

1. Recognize: What manifestations indicate H.M. had a COPD exacerbation?

Increased dyspnea, increased work of breathing (at rest) and a change in the color, amount, or

other characteristics of one’s sputum (e.g., becoming thick, purulent, when patient normally

expectorates thin, clear secretions).

2. Analyze: What is the most likely cause of her exacerbation?

Smoking and air pollution exposure as a police officer.

3. Analyze: Why would H.M. “feel full fast” when eating? What could you do to address this

issue?

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 Sensations of feeling full after consuming small amounts can be attributed to swallowing air

while eating, side effects of medication (especially corticosteroids), and the abnormal position

of the diaphragm relative to the stomach (in association with hyperinflation of the lungs).

4. Analyze: What symptoms indicate overuse of inhalers? Which drug would cause the symptoms

described?

“Jitters” and “racing heart”; the Ventolin HFA would be the primary cause.

5. Analyze: Interpret the ABG on admission and 24 hours post-admission. In comparing both

ABGs, do you see a pattern?

ABG in ED: Partially compensated respiratory acidosis:

 pH: 7.34: low, thus acidosis (normal 7.35 to 7.45)

 PaCO2: 59 mm Hg: high (normal 35 to 45 mm Hg), thus the cause of the acidosis

 HCO3-: 27 mEq/L (normal 22 to 26 mEq/L): one point over normal, thus the kidneys

are just beginning to compensate by conserving bicarbonate and trying to bring the pH

to normal.

 PaO2 68 mm Hg, she is hypoxemic (normal: 80 to 100 mmHg)

24 Hours after admission: pH: 7.30 (H.M.is becoming more acidotic)

 PaCO2: 63 mmHg (increasing, indicating a worsening acidosis)

 HCO3-: 29 (above normal, but not much change)

 PaO2: 64 (continues to indicate hypoxemia).

This is described as an “acute-on-chronic” exacerbation, as evidenced by worsening acidosis

and hypoxemia, and relatively little change in bicarbonate.

6. Priority Decision: Based on the assessment data presented, what are the priority clinical

problems?

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 Impaired respiratory system function, nutritionally compromised, activity intolerance,

deficient knowledge, substance abuse (e.g., continued cigarette smoking)

7. Act: What is one suggestion you could make to H.M. that could halt the progression of her

COPD?

Stop smoking.

8. Act: What should you include in her discharge planning and teaching?

Several important priorities for discharge teaching and planning must be considered before

H.M. can return home. Most priorities will involve the nurse confirming existing knowledge,

enhancing with newer knowledge, and validating retention of new knowledge.

Activity:

 Confer with HCP about pulmonary rehabilitation order, or, at minimum a one-time

consult with PT to develop home exercise program for patient.

 Encourage daily walking with increasing time and distance.

 Confer with HCP if patient qualifies for oxygen during exercise. Suggest a 6-minute walk

test.

Nutrition:

 5 to 6 small meals per day with lower carbohydrate and calories from protein/fats

 Nutritional supplements if tolerated

 Weigh weekly; if weight trends downward, contact HCP

Oxygen Therapy:

 Review O2 therapy with the patient and her husband. Include its purpose, how to safely

administer within the home setting, and re-ordering information. Assess the patient and

her caregiver for any questions.

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Respiratory Medications:

 Explain the action of the Ventolin HFA and how the symptoms she had were a direct

result of too much. Explain how the medication should be dosed.

 Explain the purpose of Ipratropium HFA, and how this medication is also to be used.

 Reinforce the use of the counter on the MDI. Ask the patient to show how she uses and

cleans her MDI and how she tells if it is empty (e.g., look at the counter).

 Explain the Advair DPI diskus and have her show use. Explain the difference between the

DPI and MDI. Explain why mouth rinses are important after the Advair and provide

written points on the difference. Explain that the Advair will prevent her from having as

many exacerbations.

 Explain that the long-acting β2-adrenergic agonists (LABA) should prevent night-time

dyspnea.

Other Medications:

 Explain about Prednisone, and its role as a steroid in helping reduce inflammation in

COPD exacerbations.

 Teach about Doxycycline, and its role in helping prevent repeated exacerbations in

chronic COPD. Ensure patient is aware that even though feeling better, it is important to

finish the full 10-day course of therapy.

 Explain the purpose of Lasix, it’s role in helping in helping reduce the overall amount of

fluid in the body (including the lungs), to help breathe easier. Explain important adverse

effects of Lasix.

Other Important Teaching Points:

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 Teach and/or gently reinforce the patient huff coughing and pursed lip breathing. Give

written materials on these techniques and have her return the demonstration.

 Discuss the cardinal symptoms of COPD exacerbation, including increased dyspnea,

increased volume and purulence of sputum, and what and when she should report to the

HCP.

9. Develop a conceptual care map for H.M.

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